Oncologists Need to Learn When to Stop Fighting

SAN FRANCISCO, CA (ASRN.ORG) --More than half of men dying of prostate cancer use hospice care — a significant increase over the last two decades — but most wait too long to enroll and can't take full advantage of the palliative care that could make their deaths easier, a study by researchers has found.

The study also found that men with spouses or partners were more likely to take advantage of hospice care and that African American men were 20 percent less likely to enroll than others.

Hospice care, usually in-home care, includes pain and symptom management, management of appetite, psychosocial and mental health services, family counseling and patient mobility services. It is not meant to prolong life but to make the patients and their families as comfortable as possible.

For hospice care to be most effective, patients should be enrolled for several weeks prior to their deaths. However, the study found most men enrolled just one to two weeks before they died, said the study's senior author, Dr. Mark Litwin, a UCLA professor of urology and public health and a Jonsson Cancer Center researcher.

"It's important that we maximize quality of life when quantity of life cannot be changed," Litwin said. "Most men are being referred to hospice too late, and that timing hasn't changed in the last 20 years, which is unfortunate. As cancer specialists, we should offer these patients the best quality of life that we can, and that often means offering them the best quality of death that we can give them."

The primary reason for the delay in referrals to hospice is that oncologists often are loathe to give up the fight, and they have difficulty predicting how long patients have left to live. Additionally, medical students are not taught that preservation of life may not be the sole goal in caring for patients.

"As doctors, we often don't want to give up," Litwin said. "We've sworn to help our patients, and a death is a failure to us. But the optimization of life should be our goal. Sometimes survival is of such poor quality that it should not be our primary goal."

Programs have been launched at the David Geffen School of Medicine at UCLA to address the importance of quality of life and palliative care, Litwin said. However, it can take time to make a significant change in the institutional mentality.

Dr. David Wallenstein, a clinical assistant professor of family medicine who works with UCLA's Palliative Care Service and serves as medical director for the Skirball Hospice at the Jewish Home of Los Angeles, agrees that patients are not referred to hospice care early enough. He has seen patients referred to hospice who die the same day they arrive.

"What would be ideal when a patient is referred for hospice care is that we have enough time to control their pain and symptoms and enhance their quality of life," Wallenstein said.

While it is difficult to pinpoint exactly how much time is enough, Wallenstein said "it would be nice to have at least a couple of weeks."

"If you have more time, you can fine tune the medications, try a variety of medications and work to minimize side effects," he said. "You can control pain pretty easily, but is the patient going to be awake and alert? Most patients prefer to be interactive with their loved ones when the end is near."

Litwin's study also found that utilizing hospice care could decrease health care costs, as hospice patients are not prescribed costly but ultimately futile therapies.

"In an era when increased attention is being focused on what to do to reign in runaway health care costs, there should be a clear focus on limiting therapies that ultimately will fail for these patients — costly chemotherapy treatments, more imaging studies, emergency room visits, lengthy ICU stays," Litwin said. "We need to eliminate costs that don't provide benefit and try to give our patients the most dignified deaths that we can."

For most prostate cancer patients, the arc from diagnosis to death is a long and often slow one, and men most often die from other causes before their prostate cancer can kill them. But there are about 30,000 men every year who will die from their disease, and providing appropriate palliative care to this population is vital, Litwin said.

"Studies have shown that the quality of the death experience is much greater when everyone has the opportunity to face the issues and say the things they need to say," Litwin said. "Looking back, family members who use hospice rate the quality of the death experience much higher than those who did not use hospice."

For the study, Litwin and his team identified 14,521 men aged 66 and older who died of prostate cancer between 1992 and 2005. Searching in-patient and physician claims, the team was able to identify those patients who enrolled in hospice care. Of the 14,521 studied, 7,646 (53 percent) used hospice care for a median of 24 days. About 22 percent of patients in the study enrolled within seven days of their death.

"Hospice stays shorter than seven days are too brief to maximize the benefit of enrollment, and individuals making shorter stays receive fewer services and benefit less from the input of the full interdisciplinary team," the study states. "Increasing appropriate hospice use may improve the quality of death for men at the end of life while rationalizing health care expenditures during this high-cost period."

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